Ambulance service gets £38 for every patient they don't take to hospital

The Ambulance service is being paid bonuses for not taking patients to
hospital in a bid to help the NHS hit controversial targets.

David Fisher who died this weekPhoto: Paul Grover

By Laura Donnelly and Alastair Jamieson

9:00PM GMT 27 Mar 2010

Patients' groups expressed horror at the "sick experiment" in which NHS managers have agreed to pay £38 for every casualty that ambulance staff "keep out of Accident and Emergency" (A&E) departments after a 999 call has been made.

The tactic is part of an attempt to manage increasing demand for emergency care amid failings in the GP out-of-hours system.

Documents seen by The Sunday Telegraph disclose that staff at Britain's largest ambulance service have been encouraged to maximise the organisation's income, by securing payments for diverting patients to telephone helplines.

The bonuses are among dozens of schemes being tried out by ambulance trusts across the country as they attempt to improve their emergency response times and help A&E departments meet controversial targets to treat all patients within four hours of arrival.

Another plan uncovered would see thousands of 999 calls currently classed as urgent downgraded so that callers receive telephone advice instead of an ambulance response.

The changes were due to be introduced across the country this week, but the Government committee governing ambulances has delayed its decision amid safety concerns.

Last week, an investigation was launched at the ambulance trust piloting the scheme following the death on Thursday of a man whose case was referred for telephone advice when an ambulance should have been immediately dispatched.

Katherine Murphy, from the Patients' Association, expressed horror at the potential risks being taken to ensure Government targets are met.

She said: "This is a sick experiment being played out on the public, at a cost to people's lives. These incentives are not just deeply unethical, but clearly dangerous. The patient has been forgotten."

Conservative health spokesman Mike Penning described the bonus payments as a "desperate" attempt to tackle a crisis in the emergency care system, which had been caused by Labour's policies.

He said the combination of rigid targets in A&E departments, and difficulties accessing GPs at weekends and evenings, meant "the system is falling apart".

The Sunday Telegraph has discovered that dozens of Primary Care Trusts in London are now paying the capital's ambulance service a £38 bonus for each patient crews do not send to hospital.

While the maximum amount of money the ambulance service can make from the scheme is "capped," board papers suggest increasing the number of patients diverted from hospital by 20 per cent a year "in order to reach the maximum level of funding available".

In the current financial year, London Ambulance Service has made £850,000 through the scheme.

Earlier this month, ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire abandoned plans to reward crews with shopping vouchers if they sent patients to a GP, instead of taking them to hospital.

South Central Ambulance Service had offered paramedics raffle tickets to win £200 of store coupons if they used the GP referral scheme, but dropped the plans following fury from crews.

Jonathan Fox, from the Association of Professional Ambulance Personnel said the use of financial inducements for individuals or organisations was too dangerous.

The paramedic said: "Trusts simply shouldn't put finances ahead of the clinical need of the patient; it is too risky and puts too much pressure on staff.

"Time and time again we come across incidents where red flags that a patient's situation is life-threatening are missed.

"Not every patient sent to hospital needs to be there, but paramedics need to take decisions based on what is best for the person they are treating, not the finances of their trust."

London introduced the bonus payments ahead of a pilot scheme to downgrade more than a dozen categories of calls currently classed as urgent and requiring a "blue light ambulance".

Since October, calls – including those involving stab victims and people suffering breathing difficulties – have been downgraded by London Ambulance Service.

More than a dozen types of medical crisis currently designated as urgent, and requiring a blue light ambulance within 19 minutes are instead either passed to telephone advisers or phoned back within 15 minutes of dialling 999.

The changes had been due to be introduced nationally, from this week.

However, concerns about the safety of the scheme have caused a delay, with a decision by a Government advisory committee now put back until next month.

On Thursday, there were furious clashes at the headquarters of London's ambulance service when it emerged that a 999 call about a dying man had been passed to the telephone helpline.

By the time advisers realised that the symptoms suffered by David Fisher, 76, from East London, were life-threatening, and sent an ambulance, the retired teacher could not be saved.

His partner Antony Croot dialled 999 just before 1am on Thursday, after Mr Fisher, who had a history of heart problems, collapsed at home.

When the call handler categorising the call chose between two responses, both of which had previously generated an urgent ambulance response, the screen did not warn them that one selection had been downgraded.

In selecting an option relating to Mr Fisher's struggle to breathe, rather than his history of heart problems, the call was diverted to telephone advisers.

By the time they realised that the elderly man's symptoms were life threatening, and despatched paramedics, who attempted to save his life, nothing could be done.

His bereaved partner said he could not fault the paramedics, and only hoped the delay sending the crew would not have affected Mr Fisher's treatment.

"It is just too awful to think it would have made a difference," said Mr Croot.

Abnormal breathing can indicate a host of high risk conditions, including heart problems, as it did in the case of Mr Fisher.

Other controversial categories downgraded under the pilot scheme include a puncture wound to a peripheral artery, which could result from a stabbing.

A report by the ambulance trust on the pilot scheme, which was written last July says: "Inevitably utilising telephone triage and advice rather than the dispatch of an ambulance may involve an increased risk".

The paper concludes that the level of danger is acceptable, but says the scheme should be supported by a "communication strategy" to make staff and public aware of the new response to emergency calls, and "remove the potential for disappointment".

But last night the ambulance trust refused to disclose details of the 13 categories downgraded.

A spokesman said that following concerns expressed regarding the management of Thursday's incident, technical changes had been made so that handlers were warned if any decisions involved categories which were part of the trial.

He said the trust's financial incentives were "part of a strategy to help manage overall demand in a clinically more appropriate manner".

The disclosures follow calls for an inquiry into the way ambulance services are run, following this newspaper's investigation earlier this month into risks in the operation of 999 software, which may have caused hundreds of deaths.

The problems were exposed by the death of Bonnie Mason, a nurse from Suffolk, whose response was delayed by failures in the handling of the automated system.

Last year a Sunday Telegraph investigation found that thousands of 999 patients were being left to wait in ambulances in car parks and holding bays, or in hospital corridors – in some cases for more than five hours, before they could even join the queue for hospital treatment.

Experts warned that hospitals were delaying patients in ambulances in order to help them meet the four hour A&E target.

A Department of Health spokesman said: "It is absolutely right that patients with more minor conditions can be treated by paramedics at their home or by a GP or district nurse instead of going to A&E. This is better for patients, and means A&Es can focus on the seriously ill patients who really need them."